Socio-Cultural Determinants of Health-Seeking

Behaviour on the Kenyan Coast: A Qualitative Study

Amina Abubakar1,2,3*, Anneloes Van Baar1, Ronald Fischer4, Grace Bomu2, Joseph K. Gona2,
Charles R. Newton2,5
1 Utrecht University, Utrecht, The Netherlands, 2 Centre for Geographic Medicine Research-Coast, KEMRI, Kilifi, Kenya, 3 Tilburg University, Tilburg, The Netherlands,
4 Victoria University of Wellington, Wellington, New Zealand, 5 University of Oxford, Oxford, United Kingdom

Abstract
Background: Severe childhood illnesses present a major public health challenge for Africa, which is aggravated by a
suboptimal response to the child’s health problems with reference to the health-seeking behaviour of the parents or
guardians. We examined the health-seeking behaviour of parents at the Kenyan coast because understanding impediments
to optimal health-seeking behaviour could greatly contribute to reducing the impact of severe illness on children’s growth
and development.

Methods and Results: Health-seeking behaviour, and the factors influencing this behaviour, were examined in two
traditional communities. We held in-depth interviews with 53 mothers, fathers and caregivers from two rural clinics at the
Kenyan Coast. Biomedical medicine (from health facilities and purchased over the counter) was found to be the most
popular first point of treatment. However, traditional healing still plays a salient role in the health care within these two
communities. Traditional healers were consulted for various reasons: a) attribution of causation of ill-health to supernatural
sources, b) chronic illness (inability of modern medicine to cure the problem) and c) as prevention against possible ill-health.
In developing an explanatory model of decision-making, we observed that this was a complex process involving
consultation at various levels, with elders, but also between both parents, depending on the perceived nature and
chronicity of the illness. However, it was reported that fathers were the ultimate decision makers in relation to decisions
concerning where the child would be taken for treatment.

Conclusions: Health systems need to see traditional healing as a complementary system in order to ensure adequate access
to health care. Importantly, fathers also need to be addressed in intervention and education programs.

Citation: Abubakar A, Van Baar A, Fischer R, Bomu G, Gona JK, et al. (2013) Socio-Cultural Determinants of Health-Seeking Behaviour on the Kenyan Coast: A
Qualitative Study. PLoS ONE 8(11): e71998. doi:10.1371/journal.pone.0071998
Editor: Nicholas Jenkins, Edinburgh University, United Kingdom
Received October 29, 2012; Accepted July 10, 2013; Published November 18, 2013
Copyright: ß 2013 Abubakar et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The study was funded by an internal grant by Utrecht University to Amina Abubakar and Anneloes Van Baar. The funders had no role in study design,
data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: A.AbubakarAli@uvt.nl

Introduction Observations indicate that if parents perceive a certain illness to be

Each year, millions of children die of preventable and treatable
conditions - largely in low- and middle-income countries - because
they do not access biomedical treatment in a timely manner [1].
Among those who survive early severe ill-health, there is
documented impairment in cognitive and social emotional
functioning which can persist, causing a significant impact on
the individual, the household and the community [2,3]. The lack
of timely and adequate medical care is a significant contributor to
mortality and morbidity in these resource-poor settings. Inade-
quate financial resources and an under-resourced health care
system contribute to delay in accessing medical facilities. These
two cardinal factors only partially explain the observed trends in
low uptake of optimal treatment patterns [4]. Earlier studies
indicate that a range of other factors - such as the relatively low
status of women [5], cultural beliefs and practices [6], and
perception of the cause of the illness [7] - may contribute to this
delay for parents to access medical care for their children.
unrelated to biomedical causes, they are less willing to go for
biomedical care, or at the very least, may delay the speed at which
they take up biomedical care [4]. These observations point to the
central role of socio-cultural factors in determining health-seeking
behaviour.
Previous research in Africa has investigated parental percep-
tions of the aetiology of different diseases, and their health-seeking
behaviour. The focus has largely been on describing socio-cultural
determinants of health-seeking behaviour in the context of specific
health conditions; but these studies have largely focussed on
malaria [8,9], malnutrition [5,10] and epilepsy [11–13]. However,
there is a need to take a non-disease-specific perspective, since in
certain cases some health-related beliefs and practices may be
pervasive and may influence health-seeking behaviour in different
contexts. A good example of this is provided by the issue of Abiku
among the Yoruba [7]. Abiku refers to a belief that some children
are from the spirit world, and will die at will. Consequently, some
mothers recommend that the care for these children would be

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 Health Seeking Behaviour at the Kenyan Coast

different from that of normal children. With no specific set of
syndromes , the diagnosis of abiku is largely based on the child’s
non-response to treatment (both biomedical and traditional) and
upon confirmation by traditional healers [14]. This belief in a
‘spirit child’ may influence the treatment of children with different
chronic illnesses. Consequently, investigation of health-seeking
behaviour may require a non-disease- specific approach.
We focussed on the general conceptualisation of ill-health and
management of disease through identification of common themes
across different childhood diseases. The strength of this approach
lies in its potential to identify underlying themes in the way local
communities perceive ill-health, and attempt to manage it. In
addition, the current study addresses some of the identified
knowledge gaps by carrying out a broad- based study of
perceptions of health and influences on health-seeking behaviour,
based on information from both the mother and the father. The
main research questions addressed here are:
In Msambweni the study took place within the catchment area
of Msambweni District Hospital. Msambweni district is situated at
the South coast of Kenya, near the Tanzania border. The district
has an estimated population of 283, 658 [18]. The community is
rural and depends on crop agriculture as its major source of living.
It is estimated that 57% of the population lives below the poverty
line. The people belong predominantly to three ethnic groups,
with the Digos being the majority, followed by the Durumas. The
main language spoken is Kidigo with Swahili as the lingua franca.
It is a malaria-endemic area with high rates of malnutrition.
Ninety percent of the population is Muslim. The traditional way of
life and customary beliefs of the Digo community are quite intact,
and people still use traditional healing practices on a day-to-day
basis [19]. Similar to Kilifi, it is common to find households with
three generations, also consisting of a large homestead with small
huts surrounding it, where people share various duties including
childrearing and household chores.

1. Which are the preferred treatment-seeking approaches for Study Participants and Sampling
parents at the Kenyan coast? This study was carried out as part of a larger study looking at
2. What factors influence the decision to go for either modern or developmental outcomes and parenting behaviour in respect of
traditional healing? children less than 18 months of age at the Kenyan coast. In the
3. Who makes the decision on where and when children should larger study more than 200 mothers were involved. We looked at
go for treatment? health-seeking behaviour because an earlier study indicated that
the health-seeking behaviour of parents was closely related to the
quality of care-giving. A randomly selected sub-sample of a total of
Methods 53 parents and caregivers were involved (table 1 presents a
detailed description of the sample). In-depth interviews were held
Ethics Statement individually with each of these parents and caregivers. Parents
The Kenya Medical Research Institute National Scientific and attending the Mother-Child Well Clinics were approached for
Ethical Committees approved the study. Written informed consent informed consent to join the study during routine post natal visits
was obtained from all study participants prior to participation. to the health clinics. Selecting samples from the MCH provides as
an opportunity to interview people with access to a hospital as well
Study Sites as traditional medicine. Such a sample allows us to study the
The study was undertaken in 2010 and 2011 at two rural sites at decision making process where different alternatives are available.
the Kenyan coast: Kilifi and Msambweni. In Kilifi, the study was To clarify some of the issues raised during the initial interviews,
based at the Centre for Geographic Medicine Research (coast) - another randomly selected sample (N = 5, 3 females and 2 males)
KEMRI. The Kilifi district has an estimated population of was involved in the study. Here we largely focussed on a sample
719,000 people [15]. Undernutrition is common in Kilifi, as 40% likely to give in-depth information on the meaning of indigenous
of children under five show anthropometric signs of undernutri- health-related terminology and health-related practices.
tion, and 47% present with biochemical markers of iron deficiency
[16]. Kilifi District is the second poorest district in Kenya, with Table 1. Sample Characteristics.
more than 67% of the people living below the poverty line,
indicating limited access to essential food and non-food items [17].
Most of the people in Kilifi depend on subsistence farming, but Males (N = 23) Females (N = 30)
frequent rain failure has resulted in insufficient crop yields,
Age
compromising food access in the general population. The majority
Range 20–70 17–75
of the population in Kilifi belong to the Mijikenda ethnic group.
Two Bantu languages are commonly spoken in the area, Mean (SD) 37–43(13.23) 30.23 (12.42)
Kigiriama (the local vernacular) and Kiswahili (a lingua franca Educational Status
and the national language). In the study area, 47% of the Unschooled 3 (13.0%) 5 (16.70%)
population identify themselves as Christians, 13% Muslim, 24% Primary incomplete 5 (21.7%) 9 (30.0%)
Traditionalists, 12% ‘other’, and 4% unknown [12]. A significant
Primary complete 5 (21.7%) 8 (26.7%)
proportion of the population retain elements of their traditional
Secondary Incomplete 3 (13.0%) 5 (16.7%)
beliefs and practices, which sometimes guide their health-seeking
behaviour [12]. A typical home in Kilifi comprises a large Secondary complete 3 (13.0%) 1 (3.33%)
homestead with several small huts built in the compound. In these Higher educational vocational 1 (4.3%) -
homes, extended families live together and share in the daily Higher educational university 3 (13.0%) 2 (6.7%)
chores such as cooking and fetching water. It is typical for Number of children
homesteads to have members of three different generations
Range 1–9 1–7
sharing in childrearing duties. The most senior male member of
Mean (SD) 3.70(2.42) 2.47 (1.75)
the household (seniority is largely determined by age) is usually
considered to be the head of the household. doi:10.1371/journal.pone.0071998.t001

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Data collection
Data was collected using in-depth interviews. Following
informed consent procedures, parents were interviewed in a quiet
corner away from the presence of other people. All interviews were
audio taped. Each interview took approximately one hour. The
interviews were guided by a standard set of questions to ensure
standardisation. Probes and clarifications were sought as deemed
necessary. Parents were asked to express themselves in the
language in which they were most comfortable. Sessions therefore
ran in both Kiswahili and Kigiriama or Kidigo interchangeably.
Interview tool
A checklist of questions was developed by the research team
through discussion and consensus. Refinement was based upon the
initial interviews and discussion of the initial transcripts. Table 2
presents the interview schedule used. The questions presented are
core to the interviews; however, probes were introduced to clarify
and enhance the quality of the interviews. Moreover, although the
main focus of the study was childhood disease, sometimes adults
did share their own experiences of health-seeking, and we included
the information in cases where it helped to clarify the points raised.
Data Management and Analysis
The final transcripts used for analysis were based on the audio-
taped materials. Data was analysed with the assistance of NVIVO
9 software programme according to the framework analysis
[20,21]. The transcripts of the interviews were reviewed and read
(familiarisation), during which a coding scheme was developed.
The transcripts were coded by creating ‘nodes’ in the NVIVO
programme), with each node examined separately. The first
author (AA) developed coding schemes and identified themes. The
themes identified were then evaluated and checked by one of the
authors (JG), who also independently coded five randomly selected
transcripts. Themes identified by JG were compared with those
identified by AA, with an emphasis on consistency and redun-
dancy. Any disagreements in coding were clarified by consensus.
Direct quotes arising from the discussion are presented to support
identified themes. Three of the authors - AA, JG and GB - checked
for the accuracy of the translations and interpretation of the quotes
presented.
Results
Table 2 presents an overview of all questions asked. The results
are presented in five broad themes: sources of authority in families;
treatment preferences; influencing factors; traditional healing; and avoidance of
traditional medicine. Quotes and conversational trends are presented
to support our identified themes. In these quotes, local terms
Table 2. Interview Schedule.
1. When your child is sick what steps do you take?
2. Do you have a specific person (traditional vs. alternative healer) you go to for treatment?
3. Under what circumstances do you decide to go to the traditional healer or to medical doctors?
4. Who decides on where you should take the child for treatment?
Example of probes introduced:
5. What is the purpose of the hirizi? What kind of protection does it afford?
6. What factors have made you not to go for treatment from traditional healers?
7. How did the traditional healer treat you/your child?
doi:10.1371/journal.pone.0071998.t002
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Health Seeking Behaviour at the Kenyan Coast
related to ill-health and treatment-seeking are presented, while no
direct translation of these terms are presented in the text (in an
effort to avoid changing the respondents’ meaning). We also
present the meaning of the terms used to describe different
diseases, and the closest medical translation of the terminology. In
this study, traditional medicine is used to indicate all non-
biomedical treatment sought, and these treatments are based on
cultural beliefs and practices. Earlier studies indicate that these
healing practices are influenced by the different belief systems that
are predominant at the Kenyan coast including influences from
traditional African belief systems, and Islamic influences. This
usage of the term ‘traditional healing’ is in line with the WHO
definition [22].
1. Preference of treatment
Under this theme, participants in our study indicated that
biomedicine (hereby used to refer to both attendance to clinics and
home treatment using drugs bought over the counter in shops) was
their first preference for treatment. Among our coded responses in
this node, we observed that the majority of parents approached a
medical doctor to seek treatment or used home treatment
compared to those who went first to a traditional healer and
those who preferred prayers as their first intervention for a sick
child.
‘‘I monitor them myself first, I check for fever so that before taking them
to hospital the fever should not be too high, I get them medicine to take
and if their temperature keeps rising I will run to hospital’’ [ Mother,
32 ]
‘‘First we buy medicine, we give it to them and if it does not work we
take them to hospital’’ [Mother, 29].
Other mothers noted that:
‘‘When he has fever and flu, I give him paracetamol so as to reduce the
fever. And if the temperature is really high, I take a piece of cloth, put it
in cold water and wipe the child’’ [Mother, 31]
‘‘First I buy them drugs from the shops then bring them to hospital [if
drugs did not help]’’ [Mother, 23]
‘‘Hospital, but if at home we have drugs like paracetamol, we give them
and we monitor them’’ [Mother, 34]
Despite this obvious preference for biomedicine, many partic-
ipants still responded that they had also gone to traditional/
spiritual healers. Among those we interviewed around a quarter
claimed never to have gone for traditional healing. We therefore
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explored the factors that influence people to go for traditional
healing.
2. Influencing factors
This theme had the following subthemes:
a. Disease perception/attribution of causation. The
participants noted two different types of illness which required
different treatment or management approaches. Some illnesses
were best suited to being treated by the medical doctors, while
other diseases were most suited to treatment by traditional healers
(Appendix S1). They noted that diseases such as malaria, typhoid
and fever caused by ‘natural causes’ could best be treated by
biomedicine. When they had such illnesses, they would go to
hospital.
‘‘For hospital it is like coughing, malaria, typhoid, eyes paining, and
things like that’’. [Father, 34]
‘‘When the child has malaria I take them to hospital. Also when they
have fever, diarrhea, vomiting - then I take them to hospital….’’
[Mother, 25]
Some conditions, particularly those with mental health symp-
toms such as hallucination or anxiety, appeared to be uniquely
suited to traditional healing. The following extracts exemplify the
above-mentioned conditions;
‘‘There are diseases/conditions that are abnormal, take for instance
someone who sleeps well and at night gets ill and starts screaming and
calling out to people no one else can see, then we decide that hospitals
cannot deal with this condition, and take them to experts who can see
what the person can see.’’ [Mother, 34]
‘‘Long ago, when I was young, I was taken to a traditional healer… I
had lost consciousness; I was seeing things that I could not understand,
having nightmares, dreaming I was dying …’’ [Father, 34].
‘‘To have something draw your blood until you become white, or
epilepsy, is when we take the child to a traditional healer to treat them.’’
[Father, 34].
‘‘When you feel that something is crawling in your stomach or legs.’’
[Mother, 19]
Additionally, illnesses such as ‘chirwa’ or ‘nyuni’ (Appendix S1)
which are presumed to have arisen from the breaking of taboos,
witchcraft, evil eye and spirit possession were also seen to be best
treated by the traditional healers.
‘‘Like chirwa we take it to a traditional healer, ……..also nyuni we
take it to a traditional healer or a teacher (spiritual leader) to read the
Quran since people believe it is caused by an evil spirit’’ [Father, 27]
b. Seeking alternatives. Seeking medical care in clinics and
other health centres is the first preference for those seeking
treatment for their children. However, in cases where the child’s
health deteriorates or does not seem to improve, more than half of
the parents we talked to, decided to look for other alternatives,
such as visiting a traditional healer.
‘‘When the child gets ill, I will first take them to hospital, until the
hospital cannot manage it. When it is impossible [for the hospital to
fully treat them] I will wait for the child’s father and tell him ‘let us go
and try traditional medicine, it is now time to try traditional
medicine’………’’ [Mother, 50]
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Health Seeking Behaviour at the Kenyan Coast
Another parent we talked to, noted that when treatment seems
not to work, they go for prayers to a faith healer
‘‘If I have gone to the doctor and received treatment and still see no
improvement, then if the doctors have been unable to treat, I will go to
seek prayers from a religious leader.’’ [Father, 34]
Another participant emphasised the need for traditional healing
if the conventional treatment fails.
‘‘When the hospital is unable to treat the illness then I will go to the
traditional healers…’’ [Father, 39]
Few of the participants provide a time frame within which they
moved from one treatment system to the other. One parent
mentioned that
‘‘It depends on the sickness: personally I will verify the symptoms, when
it’s a high fever I will give him/her duration of one day before taking
him/her to the hospital and during that time I will just buy painkillers
just to ease the pain but when the sickness persist then I will take him to
the hospital.’’ [Father, 45]
c. Prevention of ill health. Another important aspect of
traditional medicine that was reported by participants is its
perceived preventive potential. The parents we talked to noted
that even before a child was ill, they took various steps to protect
the child from possible ill-health. It was reported that children
were taken to traditional doctors to receive protection from various
bad occurrences including transgression of taboos, the evil or
jealous eye or witchcraft, among others. For instance, a mother
explained that if a woman has had an extramarital affair while
pregnant, she would go to a traditional healer so that she can
receive a potion to protect her unborn baby from getting ‘chirwa’.
‘‘For instance, if you are pregnant and you go out and have a sexual
relationship with a man other than the father of your unborn baby, then
you can go to a traditional healer to receive advice before having the
baby. There is a potion to be used to wash the baby [usually done after
the child has been born]’’ [Mother, 22]
Another mother explained the different ways traditional
medicine is used as preventive treatment:
‘‘Right after giving birth, there is something called ‘pande’ we tie on the
child’s waist, so in case the child’s father has a sexual relationship with
another woman (i.e. other than the child’s mother) and comes to hold the
child, the child will not get any disease. The disease is referred to by us
as ‘chirwa’ and when the child has been tied to ‘pande’ they won’t get
chirwa. There is also oil, which you are advised to apply on the child’s
shoulders going down; this is called ‘kiza’. There are also ‘vipande
vipande’ which you tie on the hands as a means of protection from ‘dege’
and ‘dzongo’’’ [Mother, 22].
The following participant explains further the conditions that
facilitate the use of amulets to protect the child.
‘‘Diseases we are protected from with amulets include ‘nyuni’ and
seizures, among others…….You may hear that a child has been
4 November 2013 | Volume 8 | Issue 11 | e71998

bewitched so that spirits can possess them, but with the right amulet they
will be protected.’’ [Mother, 29]
d. Counselling and advice of elders. In addition, we were
told by the participants that parents opted to go for traditional
healing based on the counselling and advice given by elders within
the family or the community. In the two communities that we
worked in, ignoring the counsel of an elderly person is generally
frowned upon. Therefore parents would take the child for
traditional healing even in cases where they as parents did not
strongly feel that their child was likely to receive proper treatment
by the traditional healers.
‘‘Sometimes the grandparents may advise you to take the child to a
traditional healer, or an older person may advise you to take the child to
hospital, [if you ignore them, it won’t be good].’’ [Mother, 29]
e. It is not really about money. The cost of hospital was
rarely mentioned. Our discussions with the mothers indicated that
the choice of the kind of treatment was guided more by attribution
of aetiology of the disease. For instance, in the discussion on where
they seek treatment, a participant pointed out that they would go
to the hospital for care if the treatment was free; we then inquired
why they would not spend the money they spend at the traditional
healer taking the child to hospital. They responded that they were
not sure if the hospital had the correct medicine/treatment for
‘nyuni’ or ‘vitsumbakazi’.
‘‘I would love to go to hospital if it were free, because where there is free
treatment I want to go, but there is nothing for free …… I am not sure
if the doctors at the hospitals have the correct medication for ‘nyuni’ and
‘vitsumbakazi.’’ [Mother, 22]
3. Traditional healing
Our participants reported various forms of traditional healing,
including the use of herbs, the use of prayers, religious signs and
symbols, and rites and rituals. The descriptions below show a
religious form of healing
Spiritual healing
‘‘We use medicine referred to as ‘kombe’….amongst us the healer will
take verses from the Quran, write them on a piece of paper, put in a
bottle with water and read over that …. The patient is given this (the
bottle of water) to use.’’ [Mother, 22]
Example of herbal treatment
‘‘You are given an amulet, and then given another medicine to apply on
the forehead. ……..There are herbal roots that you are given to boil,
then drink.’’ [Mother, 40]
Another participant explained, in a slightly more detailed form,
his treatment after being possessed by a spirit and the hospitals
could not offer adequate treatment.
‘‘I had been employed at a construction site. In the evening when I was
sleeping, I saw something like a bomb coming to hit me, then I had
someone in my sleep telling me to wake up, not sure who but I think it
was God’s strength (grace), and when I woke up something {that could
not be seen} hit my body. I went to the medical doctors; they examined
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Health Seeking Behaviour at the Kenyan Coast
me but they could not identify the problem. When I went to work I
would cry and complain [because of pain], but no one could understand.
So I went to a traditional healer who said that someone had sent to me a
‘jinii’ (spirit).
We looked for chicken, a goat, and some herbal roots. I was given some
to use while bathing and the other to drink. The timing for using the
medicine was just like the hospital one i.e. morning and evening; and
with God’s help I now feel OK.’’ [Father, 52]
4. Avoidance of traditional medicine
As noted earlier, most of our interviewees reported that they
used both traditional and biomedicine. However, almost a quarter
of those interviewed claimed never to have used any alternative
healing at any point in their lives. Given the prevalence of its use in
these two communities, we were interested in understanding what
made this group of people not go for traditional healing. A
common reason given was that traditional healing was found to be
out-dated. People expressing this view thought that it was
backward and irrelevant for people in the modern world to still
go for traditional healing.
‘‘Traditional healers are there, but the use of traditional healers belongs
to the old days, that is why we now have hospitals. When you take your
child to a traditional healer, they will pour cold water on them, and
make them even more ill.’’ [Father, 32]
‘‘I am civilised and educated, so my decision is to go directly to a
medical doctor’’ [Father, 34]
For some of the participants, the main reason they did not go
for traditional healing was because they did not find it efficient.
These interviewees noted that they had observed certain members
of the community consistently going for traditional healing, and
yet their condition did not improve.
‘‘It does not heal nor does it prevent ill health, to be honest.’’ [Father,
30]
Others reported that they have not been to a traditional healer
because their children have not yet experienced any severe ill-
health that could not be treated by the hospital.
5. Sources of authority
Almost half of the participants had the view that fathers were
the ultimate decision-makers in seeking treatment. It was noted
that whenever the child required medication or was ill, the child’s
father was consulted; as noted by one mother
‘‘It is the father.’’ [Mother, 34]
A father’s role seems to be very much defined by his status as the
breadwinner in the family. It was observed the father had to be
consulted so that he could provide money to go for treatment.
‘‘From my husband….. Where else would I get money?’’ [Mother,
50]
These observations by the mothers were confirmed by the
fathers:
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‘‘It is the father who makes the decision’’ [Father, 32]
Moreover, we inquired from the fathers whom they consulted
while making such decisions. This is especially relevant in cases
where the child has been undergoing treatment for some time with
no signs of improvement; both parents make the decision on when,
where and to whom to go and seek medical care from.
‘‘It is the child’s mother, we usually sit down and talk about it, plan on
what to do next, since she is the closest person.’’ [Father, 36]
Similar sentiments were noted by other participants as is
exemplified by the quote below:-
‘‘It is me and my wife.’’ [Father, 34]
The role of the father as the decision-maker may vary as a result
of living arrangements. It was observed that when the women were
single parents or living away from their husbands, they consulted
someone else. As noted by one participant
‘‘Before one does anything they must first talk to the child’s father, if
they are living together.’’ [Mother, 31]
In cases where the husband was not around, most of the
mothers reported consulting their own parents sometimes in-laws,
and in rare cases they consulted older neighbours.
Discussion
Our study had three key findings. Firstly, traditional healing
systems coexist with the biomedical system and both complement
each other. Secondly, the biomedical system was the preferred
treatment but traditional healers are consulted when biomedical
system seemed to have failed, and for diseases perceived to have
supernatural causes e.g. mental illness. Thirdly, the decision
making process on when and where to go for treatment was
complex. This process involved various members of the family
with fathers being the ultimate decision-makers.
Traditional vs modern medical approaches
The recognition of biomedical treatment as the first choice of
treatment is in line with expected health-seeking behaviour from a
Western perspective. The practice of home treatment with drugs
largely bought over the counter has been widely reported in
Africa. For instance, in a Nigerian study [23] most of the 168
mothers included in the study used some form of home treatment
in the first 24 hours of their children’s illness. At the same time, the
high prevalence of home treatment is a concern. Earlier studies
indicated that without intervention, most people receive inappro-
priate medication or the incorrect dosage, which may contribute
to the worsening of the condition or the development of drug
resistance. There is evidence that community-based educational
interventions can improve patterns of self-medication. A good
example is the successful shopkeeper training programme in Kilifi,
Kenya [24,25]. In the shopkeeper programme, rural drug retailers
were educated on symptoms of malaria, and learned to advice on
selling the right drugs and the correct dosages. Evaluation
indicated a significant improvement in the correct usage of anti-
malaria drugs during childhood illness by both the retailers and
the community.
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Health Seeking Behaviour at the Kenyan Coast
The decision to go for traditional healing was motivated by two
main issues: a) the perceptions of the cause of the illness, and b) the
duration, severity and chronicity of the illness. We observed that in
the communities in which we worked, diseases had been
categorised into two types: the diseases that were taken to hospital,
and those that were taken to traditional healers. The diseases not
taken to hospital are largely those thought to arise from
supernatural causes such as spirit possession, witchcraft and
breaching of taboos, among others. From a Western perspective, it
also seems that psychological and psychiatric problems are
presented to the traditional healers. Our findings are in line with
earlier findings from other parts of Africa, that the perception of
ill-health in Africa is much more complex than the mainstream
biomedical approach. The mainstream model or conceptualisation
of health and illness is primarily biological approach. In this
model, disease is perceived to be an abnormal physical state
caused by bacteria, viruses, hormonal or chemical imbalance in
the body [26]. However, in many non-western settings, the
conceptualisation of well-being and ill-health is much more
holistic, involving the body, the mind and in some instances the
supernatural [26]. For example it was observed that among the
Bira of Mobala and the Nande of Mukulia, of vthe Democratic
Republic of Congo [26], the aetiology of ill-health could be
attributed to seven different causes. These ranged from natural
causes to transgression of cultural taboos (e.g. eating forbidden
food) to witchcraft.
We found that there still exists a high prevalence in the use of
traditional medicine; although there were some who observed that
it was old-fashioned. According to the WHO 2002 report on
traditional medicine, at least 80% of people in Africa use
traditional medicine at some point in their lives [22]. These
results imply that the efforts to improve health care access in Africa
cannot ignore traditional health systems. Of interest here is that
our results clearly indicate that traditional healing plays a limited
but complementary role to the formal health system. It seems as if
these two systems compete at a decision-making level within
families, rather than publically competing against each other.
Parents opt for one of the forms of treatment and if this does not
appear to be working, they opt for the other. The fact that Africa
has a severely under-resourced health care system, an approach
where modern medicine and traditional health care systems
complement each other may be the most efficient and cost-
effective way to meet the huge need for health care in the African
context. As recommended by the WHO [22], various approaches
can be used to encourage integration between modern and
traditional health systems. These could include enhancing medical
doctors’ sensitivity towards the role of traditional healing, and
encouraging traditional healers to develop some collaborative
work with medical doctors. There are various ways in which
traditional healers can complement medical doctors, for example:
acting as referral points {sending patients for biomedical
treatment}; discouraging traditional healers from any practices
that may potentially harm the patients; and encouraging and
monitoring adherence to the treatment regimen recommended by
medical doctors.
The collaboration between the biomedical and the traditional
healing system has to be guided by the need to ensure that the
population moves towards optimal health seeking behaviour. Our
results indicate that traditional healing in these communities is a
mix of various practices including herbalist, spiritualism and
practices based on superstition which is consistent with earlier
observation from researchers in this community. Previous studies
in this area indicate that the key role of traditional healing has
been to provide psychosocial and emotional support, an aspect of
6 November 2013 | Volume 8 | Issue 11 | e71998

support that could be significant in helping families cope with
chronic illness. Traditional healers were perceived to have better
communication skills thus building trust and better communica-
tion skills [12,27]. Experience from elsewhere [28] indicates that a
successful collaboration would require sensitivity to ensure the
implementation that trust and respect for each other leads to a
successful partnership.
Our findings on the relationship between people’s beliefs and
health-seeking behaviour further support earlier reports on the link
between behaviour and health outcomes. As noted by Taffa and
Chepngeno [29], such associations between belief and behaviour
enhance the possibility of reducing the occurrence of life-
threatening illness, and its impact on child development, through
the promotion of optimal health-seeking behaviour.
Decision makers of health seeking behaviour
The decision on when and where to take the child for treatment
was ultimately made by the father. This view was held by both
parents. Fathers took the ultimate decision based on their positions
as head of the family, but also because they were the ones who
provided funds for seeking treatment. Our results further
emphasize the need to actively involve fathers in health
interventions and programmes so that they can make informed
decisions on behalf of their families. However, we also observed a
much stronger position of women in the decision-making process
compared to many of the earlier studies [5]. For instance, many of
the fathers said they consulted with their wives when making
decisions about treatment for their children. This was confirmed
by the women we interviewed. In summary our data show that
fathers play a crucial role in the final decision taken. It is therefore
important to emphasize that in intervention and educational
programmes, the different voices in the decision-making processes
should be taken into account.
The pattern of our results indicate that social status, educational
levels and power both within the family and larger community has
the potential to impact on health seeking behaviour. For instance,
some of the participants indicated the use of traditional medicine
was outdated and for those with limited education. It would have
been interesting to examine these patterns in greater details.
However, our sample sizes were too small to allow for this level of
analysis. Future studies investigating these effects are recom-
mended.
We interviewed both mothers and fathers as a means of
including the father’s voice into the discourse. Our pattern of
results indicate a high convergence between mothers and fathers in
their perceptions of the person who is the decision maker, on
where and when to go for treatment, and attribution on causation
of illness. This indicates there is a generally accepted cultural
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Supporting Information
Appendix S1 Table summarizing local terms related to
ill-health, causation and treatment approaches as
highlighted by participants.
(DOC)
Acknowledgments
This article is published with permission of the Director of Kemri. CR
Newton was funded by the Wellcome Trust; UK . The authors would like
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